 A 53-year-old man presented to an emergency department because of pain, swelling, and redness in his right foot, which began 3 days before. He recalled no overt trauma, but he was jogging when he first noticed the pain, which he described as a constant aching and rated as high as 8 on a scale of 10.
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 10 years ago he was diagnosed with diabetes mellitus, for which he currently takes rosiglitazone
(Avandia) 2 mg/day and metformin (Glucophage
XR) 500 mg four tablets daily.
 He also takes ramipril (Altace) 10 mg/day for hypertension, as well as a daily multivitamin.
 He has a history of hyperlipidemia and a family history of diabetes mellitus and Parkinson disease.
 He has never been hospitalized and has never undergone surgery.
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 On examination:
 Weight 104 kg (229 lb), and height 6 feet 1 inch.
 BP-160/90 mm Hg, Pulse 104, Temperature
100.4
° F (38 ° C),
 CVS: rate and rhythm were normal, with normal S1 and S2 and no murmurs.
 Lungs: clear to auscultation
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 Left foot appeared normal, but his right foot was swollen, hot, and red as far up as the lower leg, and it was hard, especially on the dorsal side; there were small patches of ecchymosis around the second and third toes
 his capillary refill was good bilaterally, and no skin lesions or abrasions were noted.
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 blood glucose level 239 mg/dL (normal 70–110),
 hemoglobin A1c 9.7% (normal 4%–6%), and
 white blood cell count 13.41 × 109/L (normal 4.5–
11.0)
 diagnosis of cellulitis
 intravenous antibiotics for 3 days and then a prescription for oral antibiotics
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 neurologic evaluation:
 a loss of protective sensation,
 contraction of the toes, and dryness,
 consistent with peripheral neuropathy.
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 cellulitis
 osteomyelitis,
 acute gout,
 abscess,
 neuropathic fracture,
 deep venous thrombosis
 Charcot neuroarthropathy
 No open ulceration or history of an open wound, infection is probably not the culprit
(diabetic foot infections begin with a direct inoculation through an opening in the skin, such as a diabetic neuropathic foot ulcer)
 DVT- asymmetric edema of the leg
 Fracture-location of the edema and ecchymosis in our the midfoot
 Gout pain is severe, with rapid onset, and slowly improves even without treatment
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A plain anteroposterior radiograph shows no osseous abnormalities
Stage 0
Taken 3 to 4 months after the initial presentation, Charcot neuroarthropathy has progressed to stage 2 after delayed immobilization.
Stage 2
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 Stage 0 (inflammation): characterized by erythema, edema, and heat but no structural changes
 Stage 1 (development) :bone resorption, bone fragmentation, and joint dislocation.
 Stage 2 (coalescence): involves bony consolidation, osteosclerosis, and fusion after bony destruction. Absorption of small bone fragments, fusion of joints, and sclerosis of the bone
 Stage 3 (reconstruction): osteogenesis, decreased osteosclerosis, and progressive fusion. Healing and new bone formation occur. Decreased sclerosis and bony remodeling signify that the deformity (for example, subluxation, incongruity, and dislocation) is permanent
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 25% of diabetics with this pathology had wrong initial diagnosis as-infection, gout, arthritis, fracture, venous insufficiency, and tumor
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Offers the highest diagnostic accuracy ligamentous disruption, concomitant joint deformity, and the center of signal enhancement within joints and subchondral bone (In complex regional
pain syndrome no changes occur)
 4 to 6 weeks after presentation shows areas of significant bone marrow edema of the navicular, medial, middle, and lateral cuneiform bones, and at the bases of several metatarsal bones.
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 IMMOBILIZATION- cast (8 to 12 weeks) later removable braces or a Charcot restraint orthotic walker (4-6 months)
 BISPHOSPHONATES may help prevent bone resorption
 SURGERY
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 The patient’s condition resolved, with eventual multiplanar deformity and with widening of the midfoot and increased pressure points.
 He is able to wear an extra-depth shoe, with a custom total contact inlay.
 He continues his profession as an attorney and goes about his normal daily activities; however, he is no longer able to golf and must limit his walking.
 He subsequently developed ulcerations to both feet, but they resolved with conservative wound care and surgical care.
 He is seen in the diabetic foot clinic every 6 to 8 weeks.
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 No specific lab test for Charcot exsists
 Leukocytosis, an elevated C-reactive protein and erythrocyte sedimentation rate, and recent unexplained hyperglycemia suggest infection
 In this patient antibiotics did not improve his condition
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 the reconstruction stage with resolved edema, absence of osteosclerosis, and relative osteopenia.
 Also seen is healing of the fractures of the second and third proximal phalanges, the site of the ecchymosis
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